Infertility and Assisted Conception

Question 1

how long are patients waiting for treatment?

Answer 1

less than 12 months

Question 2

how many cycles of IVF/ICSI are offered where there is reasonable expectation of a live birth?

Answer 2

three

Question 3

what are the common indications for ART?

Answer 3

endometriosis 
male factor infertility 
tubal disease
unexplained reasons 
ovulatory disorder
multiple male and female factors

Question 4

other than the common ones, what are the other indications for assisted conception treatment?

Answer 4

fertility preservation in cancer, transgender patients and social reasons
treatment to avoid transmission of blood born viruses between patients
pre-implantation diagnosis of inherited disorders
treatment of single parents or same sex couples
treatment with surrogacy when absent / abnormal uterus

Question 5

before treatment begins, what lifestyle factors must be checked / put in place?

Answer 5

alcohol = females limit to 4 units per week
weight = between 19-29
smoking = stop
folic acid = 0.4mg/day preconception-12 weeks gestation
rubella = immunise
smears = up to ate
occupational factors = avoid hazards
drugs = prescribed, OTC and recreational
screen for blood born viruses
assess ovarian reserve = antral follicle count or AMH

Question 6

what assisted conception treatments are available?

Answer 6

donor insemination 
intra-uterine insemination (IUI)
in vitro fertilisation (IVF)
intra-cytoplasmic sperm injection (ICSI)
fertility preservation 
surrogacy

Question 7

when is intra uterine insemination indicated?

Answer 7

sexual problems
same sex relationships
discordant BBV
abandoned IVF

Question 8

how is IUI carried out?

Answer 8

can be in natural / stimulated cycle

prepared semen inserted into uterine cavity around time of ovulation

Question 9

what are the indications for IVF?

Answer 9

unexplained (>2 years durations)
pelvic disease (endometriosis, tubal disease, fibroids)
anovulatory infertility (after failed ovulation induction)
failed intra-uterine insemination (after 6 cycles)

Question 10

what are the two phases of ovarian folliculogenesis?

Answer 10

tonic phase (65 days) = primary and secondary follicles to antral follicles

growth phase (20 days) = antral follicles 3-5mm to pre-ovulatory follicle (20nm), dependent on gonadotrophin

*in a stimulated cycle, gonadotropins during early follicular phase result in synchronised growth of all follicles (approx 1.5mm per day)

Question 11

what is the first stage in IVF treatment?

Answer 11

down-regulation

• synthetic gonadotrophin releasing hormone analogue or agonist
• switches off egg production
• allows precise timing of oocyte recover by using HCG trigger
• side effects = hot flushes and mood swings, nasal irritation and headaches
• scan performed

Question 12

what is the second stage in IVF treatment?

Answer 12

ovarian stimulation

• gonadotrophin hormone containing either synthetic or urinary gonadotrophins (FSH +/- LH)
• can be self administered sc injection
• causes follicular development

Question 13

what does HCG injection cause?

Answer 13

mimics LH causing resumption of meiosis in oocyte, 36 hours before oocyte recovery

Question 14

what is the third stage of IVF and what are the risks of this?

Answer 14

oocyte collection

risk = bleeding, pelvic infection, failure to obtain oocytes

Question 15

what is the job of the embryologists in maturing human egg?

Answer 15

search through follicular fluid
identify eggs and surrounding mass of cells
collect them into cell culture medium
incubate at 37oc

Question 16

what is the fourth stage in IVF?

Answer 16

sperm collection

abstinence for 72 hours beforehand, produced in mens room in ward or at home (within 1 hour)

assessed for volume, density (number of sperm), motility (what proportion are moving), progression (how well they move)

Question 17

what is the fifth stage of IVF?

Answer 17

fertilisation

*two pronuclei, male and female genetic information, approx 60% of eggs fertilise normally

Question 18

what is the sixth stage of IVF?

Answer 18

embryo transfer (usually on day 5 after fertilisation)

• normally transfer 1 (max 3)
• luteal support: progesterone suppositories for 2 weeks

Question 19

how long after oocyte recovery is a pregnancy test performed?

Answer 19

16 days

Question 20

what are the indications for ICSI?

Answer 20

severe male factor infertility
previous failed fertilisation with IVF
preimplantation genetic diagnosis

Question 21

what will be required for ICSI in the case of azoospermia?

Answer 21

surgical sperm aspiration

*can be extracted from epididymis (if obstructive) or testicular tissue (non-obstructive)

Question 22

what is the process of ICSI?

Answer 22

each egg is stripped
sperm immobilised
single sperm injected
incubate at 37oc overnight

Question 23

what is the biggest complication of ART?

Answer 23

ovarian hyper-stimulation syndrome

Question 24

what are the symptoms of ovarian hyper-stimulation syndrome?

Answer 24

mild = bloating, mild abdo pain, ovarian size <8cm

moderate = moderate abdo pain, nausea + vomiting, ascites on US, ovarian size 8-12cm

severe = clinical ascites, oliguria, haematocrit >0.45, hyponatraemia, hypo-osmolality, hyperkalaemia, hypoproteinaemia, ovarian size >12cm

critical = tense ascites/large hydrothorax, haematocrit >0.55, high WBC, oliguria/anuria, thromboembolism, ARDS

Question 25

how can ovarian hyper-stimulation syndrome be prevented?

Answer 25

low dose protocols

use of antagonist for suppression

Question 26

how can OHSS be treated before embryo transfer?

Answer 26

elective freeze

single embryo transfer

Question 27

how can OHSS be treated after embryo transfer?

Answer 27

monitor with scans and bloods
reduce risk of thrombosis (fluids, TED stockings and fragmin)
analgesia
hospital admission if requires IV fluids / more intense monitoring/paracentesis

Question 28

how have multiple pregnancy rates been decreased in IVF?

Answer 28

the move to blastocyst transfer
improved cryopreservation
increase in single embryo transfer

Question 29

currently, what % of babies born from ART are multiple pregnancies?

Answer 29

10%

Question 30

what is the biggest complication of ART?

Answer 30

ectopic pregnancies

*incidence increased 2-3 fold with IVF

Question 31

what are other problems associated with ART?

Answer 31

no eggs retrieved (v uncommon)
surgical risks of oocyte retrieval (bleeding, infection)
surgical risks of surgical sperm aspiration (haematoma, infection)
failed fertilisation 
problems in early pregnancy 
increase risk in on-going pregnancy 
psychological problems 
failed treatment

Question 32

what body regulates and licences all ART activities?

Answer 32

human fertilisation and embryo authority (HFEA)

• regulate all treatment and research
• consider welfare of child
• rights of people seeking treatment to appropriate care
• respect for human life at all stages of development

Question 33

what is the current success rate for IVF?

Answer 33

35%